Becoming an Agent of Change

Published in British Medical Journal (BMJ) Learning as a training module with 1hr CME credit.
http://learning.bmj.com/learning/search-result.html?moduleId=5004461

Becoming an agent of change: key principles and practical examples of managing change

 

Learning outcomes:

After completing this module you should know about change management as a discipline as well as your role and contribution to change. You should also know how to start putting what you have learnt into practice. You should:

• Be able to define and recognise change
• Know the difference between change and transition
• Be able to describe the three stages of transition and the four phases of response to change
• Be able to outline the steps for implementing change effectively
• Understand your role and contribution as an agent (or champion) of change.

A Patient Safety Revolution

(This article was published in Arab Health magazine http://content.yudu.com/A1tvqk/ISSUE4/resources/5.htm)

Patient safety is one of the most fundamental principles of medicine as a profession. Hippocrates got it right thousands of years ago when he started his medical oath with “First, do no harm.” Fast-forward to now; while graduating medical students still recite some version of the Oath, the statistics of medical errors are sobering. Management and technology solutions are paving the way for a revolution in patient safety.
I studied and practiced medicine in the Middle East before moving to the UK and witnessed firsthand the importance of patient safety and how the public perception is no different here compared with the West. Until we have clearer statistics on patient safety in the Middle East, let's look at the highest healthcare spending country in the world (14% of GDP). In the US, adverse drug events and patient falls cost hospitals $4.5 billion annually. As many as 780,000 surgical site infections occur each year, up to 60 percent of them preventable. Ventilator-associated pneumonia (VAP) accounts for up to 18 percent of all hospital-acquired infections, affecting some 250,000 patients per year and causing 1.75 million excess hospital days.

Challenges and opportunities

Through the use of advanced event reporting and analyzing systems, every incident (challenge) can be recorded and investigated to understand their root-cause and come up with ways to prevent future ones (opportunity). Frustrations arising from patients as victims of medical errors are also shared by healthcare providers. Patients put their trust in the healthcare systems starting from “doctors know best” to leaving almost all decisions down to their treating clinicians. Healthcare providers also get frustrated when they put all that effort, dedication and commitment into their jobs, only to find out that errors could have been avoided or a better system would have ensured more quality, better reliability and transparent accountability.
 

New era in patient safety

As healthcare systems are being redesigned to focus on measurable outcomes, the delivery system itself is also becoming an increasingly important factor in the provision of safe quality care. Health planners now recognize that healthcare is a function of organization design and not individual effort. We no longer weave our healthcare organizations around surgeons and physicians as the axis of delivery, rather, we are truly moving toward a patient-centric healthcare continuum. However, as a note for caution, methods and tools are not outcomes by themselves; evidence based performance is the ultimate outcome. That’s why GE Healthcare Performance Solutions partners with healthcare organizations to implement transformational change that suits the target organization culture using systems thinking combined with assistive technologies to deliver accessible, high quality safe care for patients.
For example, in the United States, Kent Hospital – along with a number of hospitals in Rhode Island – experienced several serious patient safety events. To improve safety and address these events, Kent implemented GE Healthcare’s Medical Event Reporting System (MERS) to track and analyze safety events and address the root causes of error.  The reporting tool empowered the staff to report not only when events occurred, but also when errors might have occurred. Recognizing that true change was only possible if accepted by the hospital’s staff, Kent also implemented cultural change strategies to ease transition to software reporting and cultivate executive communication. In just 7 months, Kent recorded 1,993 reports – up from 1,356 for the total Fiscal Year 2010. In addition, within 30 to 45 days after the system went live, Kent received enough reports to identify two processes of the hospital where near-miss events were an issue: the laboratory specimens and radiology orders. Measures are now being taken to correct processes and reduce the potential of future errors.

Simple change, big gain

In 2006, I wrote about “back to basics” in the British Medical Journal to emphasize that by applying management concepts, healthcare performance can be enhanced and outcomes improved. All healthcare processes start and end with the patient, and using techniques such as value stream mapping provides the ability to employ system-wide thinking to reorganize the way we deliver healthcare.
From appointment booking, through patient hand-offs and all the way to discharge and beyond, if we start/continue looking at the process through patients’ eyes, not only will we identify opportunities for improving quality and avoiding errors, but we will save time and effort and allow more space to have embedded checks and balances to ensure sustainability in the newly adopted quality measures. Quick-fixes and short-term “bandages” should be avoided; we are aiming at longer term system-wide approach.
 

Leaning healthcare: process sapiens

GE helps its clients through the use of lean methods to remove non-value added steps from any given process. The aim is to simplify, streamline and standardize processes to be able to do the right things the right way first and every time. The success of lean thinking is strongly supported by academic research; however there is still a hurdle to be overcome. Maria Rieders, an adjunct professor of operations and information management at Wharton, has observed various lean healthcare initiatives. Over the last few years, she says, hospitals have systematically decreased the number of infections by standardizing their procedures. Healthcare professionals are dedicated and well-educated people who focus on doing the best at all times. However, the challenge they face is that whilst they are very good at coming up with a quick solution when faced with a problem, they are not trained to be “systems thinkers.”
GE Healthcare is committed to helping professionals deliver safer patient care and has set in motion a revolution in how to tackle this issue. GE Healthcare Performance Solutions has established a Patient Safety Organization (PSO) as both a think-tank and a delivery arm to put together concepts and implementable solutions to minimize medical errors. While technology is definitely helpful, like Medical Event Reporting System (MERS), the Performance Solutions team is also adapting methods and tools used in other process-intensive industries (like aviation, energy and retail) to apply best practices and quality systems (like Lean, Six Sigma) into the healthcare sector. Through the unique adoption and use of IT, analytics helps provide new insights uncovering new ways to prevent and address any areas within healthcare processes that are error-prone.
Medicine is both an art and a science; so is lean. True change in patient safety will only come when we think beyond data, methods and techniques, and focus on acceptance, culture and behaviour of all those involved in delivering the change initiative focused on safe quality care to the patient..

Simple Change, Big Gain

The role of managers in the provision of healthcare.

(This article was published in the British Medical Journal http://careers.bmj.com/careers/advice/view-article.html?id=1998)

Do any of these sound familiar: cancelled appointments, delayed or lost results, no access to patient records or history, “same problem, every day, for years,” and a surgeon told to “go slow” because he is too efficient? [1]

 

Imbalance

Often the quality of service provided by healthcare professionals does not match their dedication and aspirations. This imbalance presents a case for review from inside the healthcare system. No single solution will fix all of the above mentioned situations, but small changes can make daily work more efficient. As you have probably guessed, in this article I will be talking about the role of healthcare managers.
I will make one point first: this article is not about the National Programme for Information Technology (NPfIT) and its benefits. NHS Connecting for Health, a relatively new agency of the Department of Health, has a well written website with all the related information. [2] The set of changes that will be introduced to health care in England and Wales by NPfIT will lay the foundation for a more efficient system. However, these changes will have to start from within the community of health professionals. Healthcare managers can help facilitate these changes because they will have a critical role in bringing these modifications successfully to the fore. Of course, we will need an NHS care records service, choose and book, electronic transmission of prescriptions, a national network, contact, picture archiving and communications systems, and IT supporting general practitioners. But as you can see from the NPfIT portfolio (see box for definitions), these are mere systems that will be put in place, and health professionals will be left to work them out. This article is about going back to the basics of management and its timeless principles, and how healthcare managers can facilitate the work of health professionals.

Impact of simple changes

A recent edition of Harvard Business Review gives examples of how simple and relatively easy changes could have a great impact on the daily work of health professionals. [3] Steven Spear, a senior fellow at the Institute for Healthcare Improvement in Cambridge, Massachusetts, argues that in the United States medicine does not deliver on the science it employs. I think we can add technology to this statement as one of the short changed assets. Healthcare safety expert Lucian Leape compares the risk of entering an American hospital to that of parachuting off a building because of the number of people who die each year in US hospitals from medical errors. [4] This is happening in a country that is committing trillions of dollars to its healthcare budget. The UK government has already secured billions of pounds for NPfIT. So the issue is not solely financial. It is not that health professionals don't care either. People working in health care are typically intelligent and well trained and have chosen their careers expressly to cure and comfort. Spear has followed several projects over the past five years. These projects are about opportunities that need little capital, can be started immediately, and in most cases can be realised in the near term. Before I summarise the main points of his work, you need to understand why there is a gap between the skills and intentions of healthcare professionals and the US healthcare system's performance. Spear argues that the problem arises partly from the system's complexity. This inherent complexity creates many opportunities for confusion, especially in a multi-team care setting. On the other hand, healthcare workers contribute to the problem by adapting a “work around” culture. Rather than improving the process of doing their daily jobs, they just adopt a short term measure. The quick fix then becomes an almost permanent solution as the involved team becomes accustomed to it as their daily routine.
Here is a summary of two of Spear's case studies and projects.

Theme: ambiguity

Preparing a patient for surgery requires a number of steps, one of which is to take blood samples for investigation. Nurses at Western Pennsylvania Hospital were uncertain whether blood had already been taken from admitted patients or not. So, visual indicators were introduced to identify which patients needed the procedure. The second uncertainty was who should do it. The unit designated a staff member to be the sole person responsible. To be more efficient, they agreed to take samples as soon as the patient was registered. Despite all of these changes, a few patients were still turning up at the operating theatre without blood test results. The process was reviewed further, and it turned out that it was unclear where the procedure should take place. The unit converted a small closet into a room to take blood samples. With this final change, the number of patients without blood tests fell to zero and stayed at that level.
Spear noted that much of the credit for the successes at this hospital could be attributed to the problem solving support provided by the unit's clinical coordinator. In a previous incarnation of the clinical coordinator's role, it was simply about we “need this and that” and “there you have it.” Missing laboratory test results, important paperwork, and so on were on the daily to do list. The newly defined role of this particular clinical coordinator was to investigate and work with key people solving reported problems. Solutions were jointly developed, tested, and validated. Ambiguity was tackled by applying simple management skills and employing an experimenting method.

Theme: work operations excellence

Two dozen hospitals in Pittsburgh have reduced the incidence of central line infections by more than 50%. In one hospital, a team of infection control experts documented every line insertion and identified variations and shortcomings. Measures were developed to improve this procedure. Changes were designed to make it clear:
Who was to get what procedure. For example, a new rule was introduced whereby all new admissions with central lines were to have new ones so that the history of the current line could be verified

Who did which aspect of the procedure

What signals could be used to trigger the work: visual aids to prompt removal sooner rather than later, transparent dressings to give a view of the wound site (to see whether it's infected)

Precisely how each step would be carried out: new types of disinfectant, various sized surgical drapes, and a new arrangement of the kit used in this procedure was devised from controlled trials to identify best practices.

Human error

One study showed that for every death due to drug treatment error there were 10 injuries (non-fatal) and 100 instances where harm was averted. [5] Unfortunately, it is only after a patient dies or suffers serious injury that the type of mistakes and the contributing factors are studied. This is where managers and coordinators have their (other) role. Managers can help to implement a common approach to process design and implementation by encouraging “experiments” in a controlled and safe situation (even if that means a mock set up to witness and learn from daily routines with a fresh pair of eyes without the rush of “just do it now”). Healthcare managers can help turn daily work into continuous learning and learning into a collective asset of best practices. In the two examples, simple practical solutions were introduced. Managers can make sure that problems are revealed as they occur and addressed in a structured manner (where the situation permits—in emergency cases lessons learnt can be deferred). When managers work with their colleagues from other departments they can systematically deploy all these enhancements. It is by switching from “why you didn't do your work” to “why you couldn't do your work” that specifics are picked up and addressed in an organised fashion. It's a change in attitude and sometimes a change in behaviour of teamwork. This is what's needed now.

Finally, there was the story of the NHS surgeon who said he would not be forced to have a waiting list. [1] Mr Alastair Paterson, a consultant at the Royal Cornwall Hospital in Truro, said he ran a diary system, which meant seeing and speaking to patients and making a date for their operation. He has never had a waiting list. He said: “I see this as being efficient and also kind to my patients.”
Back to the examples cited in the first paragraph, can you identify a way to address these situations? And, curiously, for the efficient surgeon who was told to take it easy, I think you can see my point of how these changes can be implemented outside the frame of the NHS, can't you?

 

References

1 BBC News. Surgeon told to make people wait. BBC News  2005, 7 2 December.http://news.bbc.co.uk/1/hi/england/cornwall/4506734.stm
3NHS Connecting for Health agency: www.connectingforhealth.nhs.uk
4 Spear SJ. Fixing healthcare from the inside, today. Harvard Business Review  2005, September.
5 Leape L, Adjunct Professor of Health Policy, Department of Health Policy and 6 Management.www.hsph.harvard.edu/faculty/LucianLeape.html
7 Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. ADE Prevention Study Group. JAMA  1995;274: 29-34.

Mea Culpa – Shining a Spotlight on the Shadow of Fear Cast over Healthcare Industry

Dr Azhar Alani, MBChB, MBA

Safety in healthcare is of paramount importance. I have already written about it in Arab Health magazine (1). This article is an extension with the aim to change healthcare culture by encouraging staff to raise their hands and report all medical events to prevent serious ones.

While patients are sometimes forgiving and always understanding, efforts to improve quality of care and patient safety still have a long way to go. Improving healthcare safety is still plagued by fear, gripped by reluctance and crippled by punishment. One reason why this is the case, surveys have shown that only 44% of hospital workers are sure they will not face punishment for their mistakes (2).

What seems to be the problem?

Observation: fear of admitting and owning up to errors is manifest in healthcare delivery environment. Punishment is a hindrance if progress is to be made in patient safety and quality care. 
Empirical finding: non-harm events herald harm ones.

So, to learn from the empirical finding to address the above observation, one approach will be to encourage staff to be forthcoming and report back all events as and when they occur. If we capture and document all incidents, we will significantly improve safety and quality of care. The benefit of encouragement will be realised in the form of staff self-leadership. They will be empowered to take the initiative to deal with what’s error-prone to avoid mistakes in the first place, and prevent others from falling into similar traps.

Self-leadership is just the starting point, however. By acting as role models for others to follow, and through institutionalizing this forthcoming behaviour, culture change will be the foundation for future continuous. In other words, we need “Mea Culpa” to become the culture within healthcare. (Mea culpa / ˌmeɪə ˈkʊlpə / used when you are admitting that something is your fault. Oxford English Dictionary)

Frontiers of Patient Safety: Front-line Staff

Frontline staff team (FLS) are at the focal point of healthcare delivery and information flow. They are the single most important team to work with when it comes to improving patient safety. FLS team are in direct contact with patients and they spend the most time interacting and caring for them. This group includes all non-manager work-force who are working with patients day in, day out at the bedside, on the ward, in labs, pharmacies and ancillary services. By focusing on FLS and encouraging them to report near misses and unsafe conditions, we can take timely corrective actions to avoid serious injuries. Admittedly, it’s not an easy endeavour and would require perseverance and patience. 

The Power of Mea Culpa

The aim is to move from considering error reporting a task to help all involve to recognise it as a duty. That’s the cultural change we are trying to achieve. Mea Culpa takes a bottom-up approach and starts at grass-roots level to ensure ownership. It embodies self-leadership by encouraging taking the initiative, and demonstrates leading-by-example through becoming role models for others. Mea Culpa encourages learning by bridging the gap between knowledge and know-how, and it empowers staff to voice their concerns. There is nothing more hands-on than raising the hand. It’s not “Project of the Month,” though. This is change for good and for the betterment of all involved.

More often than not; however, change won’t happen by itself. We need to introduce methods, tools and even sometimes new technology and systems to embed change within the organization. Having a cross-functional multi-disciplinary team (MDT) will provide a holistic view when conducting root-cause analysis. Once required change is identified, we will need to expedite the implementation phase to avoid running into analysis paralysis. The implementation can be speeded up by starting with a small pilot to experiment in a carefully chosen department to create a fitting blueprint that can be rolled out to the rest of the organisation. Considering the anticipated large volume of data to be captured, and to ensure governance within the process, we may need to deploy an “event management system” to capture and report out on medical events.

Such systems are IT-based and may present challenges, in terms of financial investment, that need to be balanced with the realised benefits. Some hospitals are joining forces to have a common shared EMS where data is pooled in one place and insights and lessons learned, mined through analytics, are shared among all participating parties. Sensitive data is to be dealt with first before any such system is considered, of course.

Social Loafing

Social loafing is the tendency of individuals to put forth less effort when they are part of a group. Because all members of the group are pooling their effort to achieve a common goal, each member of the group contributes less than they would if they were individually responsible. While we focus on team work, and we all understand that today healthcare delivery is a function or organization design and not the product of individual effort, we need to pay close attention to prevent social loafing from ensuing within work environment.

There are various ways to address this situation, for example “management by walking around” and enhanced staff engagement. Both approaches are win-win methods as, not only will you avoid running into social loafing, you will also ensure all team members contribute. When it comes to patient safety, this cannot be over-emphasized.  

Appendix - Medical Errors: Definitions

• Adverse event: an injury or complication caused by medical management that prolongs hospital stay or produces lasting disability or death.[NEJM 1991;324:370-6, Med J Aust. 1999;170;411-5, BMJ 2000;320:741-4]
• Preventable adverse event: an adverse event judged as unlikely to occur if the individual or system involved in delivery care had followed practices regarded at the time as accepted (that is, non-investigational) or “standard of care.”[NEJM 1991;324:370-6, Med J Aust. 1999;170;411-5, BMJ 2000;320:741-4] 
• Error: an act of commission or omission that, based on currently available information, substantially increases the risk for an adverse event. [Eff. Clin. Pract. 2000;3:1-10]
• Quality of care: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. [Med Care. 1985;23:710-22]
• Root-cause analysis: systematic investigation technique that uses information gathered during an intense assessment of an accident to determine the underlying reasons for the deficiencies or failures that caused the accident. [Chigaco: Health Forum Inc, AHA Pr;2000: 155]

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(1) Arab Health article “A Patient Safety Revolution”Arab Health Magazine – July/August 2011 – page 42/43  http://content.yudu.com/A1tvqk/ISSUE4/resources/5.htm 
(2) OpenSafety.org http://www.opensafety.org/2011/05/16/perceptions-of-hospital-safety-climate-incidence-of-readmission/

Perspectives on the Changing Healthcare Landscape

Dr Azhar Alani, MBChB, MBA

Healthcare has finally had its eureka moment: put the patient at the centre of everything. Hence the need to look at the industry in a completely different way. If we adapt the patient’s perspective, it will be easier to recognize and manage one of the biggest issues healthcare industry is inflected with today: process waste. In the US healthcare system alone, $1.3 million is being lost every minute in non-value added activities (process waste)(1). Adapting this new perspective - the customer’s viewpoint, will help us understand why the healthcare system needs an overhaul: re-designed to be truly patient-centred. It’s not all about systems and processes, however. At the heart of this journey is changing mindsets.

Without changing mindsets, healthcare industry will remain crippled by its old ways trying desperately to adapt to new realities. One of the approaches to changing mindsets is through a consulting practice called change management: the effort to introduce new ways of doing old things focusing on the behaviour and culture to the effect of changing how people think about their work. However, we need to ask the question: how can we change the mindsets of healthcare managers; those trying to introduce change in the first place?

Changing Delivery Model

Healthcare delivery is structurally changing - archaic ways can no longer cope with the changing environment: cost constraints, patients' expectations and the plethora of new technologies. One analogy that comes to mind is the musical chairs game. This traditional group game illustrates the current situation of healthcare delivery model. By arranging a number of chairs (n), participating players (n+1) are asked to run round the chairs while music is playing. Each time the music stops, players try to sit down on one of the chairs. As there are more players than chairs, one person will be left out each round. Imagine the public healthcare delivery system as the chairs around which patients circling until all resources are exhausted and they would either go private or just endure pain. We are trying to turn this set up inside out: we want to make the healthcare delivery system circle around patients in a truly patient-centred fashion, so that patients themselves empowered with knowledge and ownership of their own medical information will be able to choose the best way to receive the care that would be suitable for their circumstances and life style. It’s the inverse of musical chairs game; if you like. 

Patient-Centred Care (PCC)

There are several interpretations for PCC. The Institute of Medicine’s (IoM) definition is a well-accepted one: ‘providing care that is respectable of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions’. Add to that the fact we in healthcare can no longer deliver what the patient needs single-handedly in a job-shop fashion as it used to be the case decades ago. Healthcare delivery is a function of organization design – team work plays a vital role in ensuring quality of care; where quality is defined by how closely outcomes meet patient’s expectations. The IoM goes on to offer a list of services and aspects that constitute PPC approach:

·         compassion, empathy and responsiveness to needs, values and expressed preferences
·         co-ordination and integration
·         information, communication and education
·         physical comfort
·         emotional support, relieving fear and anxiety - and
·         involvement of family and friends.

Patients Know Best

Disruptive innovation has been talked about and discussed inside and out of business schools around the world. Some large corporates took it to heart and established a creative milieu to foster innovation, and made sure such small satellite units are attached to the corporate head-quarters through a “dotted line” arrangement to give it as much freedom and space as needed for the new ideas to flow. A British company has tried to not only disrupt healthcare industry, but also to adapt the patient-centred care approach by changing the “musical chairs” model. Dr Mohammad Al-Ubaydli, CEO and founder of Patients Know Best(2), has devised a new subscription-based system that revolves around the patient. A medical doctor, software specialist and management consultant, Dr Al-Ubaydli represents the new generation of healthcare professionals daring to cross to the other side to change the industry inside out. “Medicine is basically an information industry. It’s all about knowing the right information of the right person at the right time,” Dr Al-Ubaydli was quoted saying as he was describing the idea behind business. In this new approach to making IT work for healthcare, Dr Al-Ubaydli wants to put patients and clinicians in the driving seat, rather than the technology being introduced. Traditionally and unfortunately now all too familiar, previous attempts to modernize healthcare using IT have failed spectacularly, if Connecting for Health (CfH) programme in the UK is anything to go by. 

From "Paternalistic" to "Participatory" Medicine

We need to move from the out-dated “paternalistic medicine” model of doctors-know-best model to the innovative and more logical for this day and age: what Dr Al-Ubaydli calls “participatory medicine” where patients are at the centre as well as taking part within the whole delivery team (clinicians, healthcare-givers, IT, others). One of the reasons Dr Al-Ubaydli attributes the failure of CfH programme to is the top-down approach that was followed in architecting the healthcare landscape in the UK. Through Patients Know Best model, individual patients have at their disposal their own information and can give permission to whoever needs access to their information as and when at the point of care. With the participatory medicine model, the focus is the other way round: it’s a bottom-up approach.
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(1) From A Global Village publication, "Enabling E—Health A Revolution for Informatics in Health Care" by Simon Kennedy & Benjamin Berk, The Boston Consulting Group http://aglobalvillage.org/journal/issue4/ihealth/kennedy/
(2) Visit www.patientsknowbest.com/

Unlocking value trapped in BMJ-rejected papers

It's been said that the BMJ* is a big rejection machine(1). Out of approximately 8,000 manuscripts received each year only 7% are accepted. Comments and suggestions provided by editors and/or reviewers represent a wealth of knowledge only available for the original authors. Is there a way we can unlock value trapped in the remarks provided by BMJ editorship?

The short answer is yes. In a study published in Occupational and Environmental Medicine journal(2), it was estimated that more than 50% of rejected papers were published somewhere else, the majority of which were issued in the first two years after rejection. Even though only 10% of those rejected were published in journals with a higher impact factor(3), one can say that not all unaccepted papers go to a lower-ranking journal. The figure of 50% appears to be common among other major journals, like Cardiovascular Research(4). I think the situation with BMJ is similar to these major papers. How could authors then succeed in publishing more than half of their rejected papers? Well, in some cases the credit goes to what can labelled as constructive criticism: comments and suggestions from the editorship of the rejecting journal. Authors in these cases incorporate changes recommended by editors and/or reviewers and sometimes even do a total rewrite. This means there is a knowledge asset that will be useful if shared with other authors.

A proposal
To answer the question of how to unlock this valuable resource, I suggest we build a database for a selection from these unaccepted papers. Below is a summary of this proposal:
a. Initially submitted manuscripts are tagged with comment markers (in technical jargon: metadata tags). While BMJ editors/reviewers are scrutinising these manuscripts, they can enter their suggestions and remarks as “Comments” to be captured by the information-holding place (ie metadata tags)
b. If this particular paper is rejected (there is a 93% chance that is the case with initially submitted manuscripts to the BMJ(5)), then all personal references are removed to de-identify the original and make it anonymous (information like author names and other bits of content chosen by the authors (to avoid copyright infringements and to protect intellectual property of the authors).
c. A database is to be created to host all of the binned material (which is now anonymous). The database system will do the job of indexing and grouping all of these materials in meaningful groups.
d. This database will then be made available for those who are about to write or submit a paper. Access will be logged and managed by the database system making sure that security measures are in place.
e. With time, there will be a build up of knowledge from the bits and pieces of information which will be contributed by editors and/or reviewers. It can be thought of as a “wisdom database” as it will be a place where accumulated scientific or otherwise learning is kept. 

Avoiding pitfalls and obstacles

Authors can learn from other people’s mistakes by examining failed attempts and analysing the reasons of rejection to understand better BMJ editors’ logic. Knowing some of the frequent errors can help steer your writing journey away from editors’ recycle bin. Sometimes it’s common sense that separates an accepted paper from a failed one. According to Jeff Skousen, a West Virginia University professor(6), “Scientists who publish know some of the pitfalls and obstacles that hinder the publishing process, especially in the top-tier journals.” With “wisdom database” in place we can alleviate the pain that many of us have to endure when trying to pass through BMJ gatekeepers (also known as editors). 

Intellectual property

Publication in scientific literature serves as a means to secure knowledge ownership claims besides being an efficient vehicle for communicating this body of knowledge. It’s one of the unwritten rules in research community that a scientific experiment is not complete until results have been published. One of the issues this proposal would face if implemented is how to address the intellectual property (IP)(7)area. I have already mentioned that it will be left to authors to decide on what to be stored and what’s not for IP reasons. I suggest we leave it to authors the choice to opt in this scheme (ie all papers are opted out unless authors decide otherwise). The area of IP would have to be examined carefully and would represent an important part of the detailed plan of this proposal if put in practice.

The future

Admittedly, this can prove a slow process; hence patience and determination from all involved will drive it forward to make it happen. It is an organic tool in the sense that it will grow dynamically and be refined as it gets larger and learn more to be “wiser.” Initially there will rapid quantitative growth as the database will increase in volume with every new article entered. With time, the database will mature and grow qualitatively. When the benefits of this database are reaped, there will hopefully be a positive effect on BMJ’s prospective authors. With this database we will create a self-tuning system of continuous refinement. To take it forward, I suggest we experiment with a pilot scheme and I will be happy to start the groundwork straightaway. I see this change, if taken up, as something that would send ripples to all other major journals. I sincerely hope that the BMJ will take the lead in this initiative. Over to you BMJ..
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Azhar Alani, MBChB, MBA
Business Management Consultant
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* BMJ - British Medical Journal, is just a representative example and not the only publication addressed by this article. Visit www.bmj.com
1)  Trish Groves, Kamran Abbasi, “Screening research papers by reading abstracts”, BMJ  2004;329:470-471 (28 August).
2)  B Nemery, “What happens to the manuscripts that have not been accepted for publication in Occupational and Environmental Medicine?” Occup. Environ Med. 2001;58;604-607.
3)  Impact factor is an indicator that reflects the average number of citations received by the average article of a journal per year. For more on impact factor: Amin M, Mabe M. “Impact factors: use and abuse.” Perspectives in Publishing 2000;1-6.
4)  Opthof T, Furstner F, van Geer M, et al, “Regrets or no regrets? No regrets! The fate of rejected manuscripts. Cardiovasc Res 2000;45;255-8.
5)  Information on analysis of papers submitted to BMJ for publication can be found on BMJ website at http://bmj.bmjjournals.com/advice/ms_breakdown.shtml
6)  M Celeste Simon, “Writing a paper that will get published” The Scientist 15[7]: 30, April 2, 2001.
7)  For more on intellectual property go to http://www.intellectual-property.gov.uk/